When
Ben Franklin coined the adage “Waste not, want not,”
he may have unwittingly inspired Henry Ford to envision the lean
production principles that Toyota fine-tuned more than half a century
later to catapult the motor company to world-class status. And Toyota
probably never foresaw that the Lean Management system, as it’s
come to be known, would one day make its way into clinical labs.

With its rigorous
emphasis on eliminating waste to improve productivity, Lean Management
has risen to the fore as a way for labs to compete on cost and quality
under fixed or dwindling reimbursement systems. The CAP ’03
annual meeting in San Diego next month will host a session on the
Lean quality management system, which a growing number of labs are
adopting or at least eyeing as a solution, albeit one that turns
traditional thinking on its head.

“The easiest
of all waste, and the hardest to correct, is the waste of time,
because wasted time doesn’t litter the floor like wasted material,
and once you lose it, you can’t get it back,” said Mark
Jamrog, president and CEO of the consulting firm SMC Group LLC,
Edwardsburg, Mich.

In laboratories,
he said, waste takes many forms: transportation, overproduction,
defective products, human potential, and information. “But
the king of all waste is the waste of time,” emphasized Jamrog,
who led a presentation on Lean Management last May at the Executive
War College sponsored by The Dark Report.

The key to Lean
Management in any industry is to keep the product in motion. In
labs, that product is “a tube of life—blood,”
said Jamrog, who has applied Lean production principles to everything
from fighter aircraft to draperies and now to clinical lab specimens.
“It doesn’t matter what the product is, the fundamentals
and principles are the same,” he told War College attendees.

Laboratories
that implement Lean strive to minimize “storage time,”
or the time that a specimen sits around waiting for something to
happen to it, which in Lean-speak constitutes “non-value-added
time.”

“That’s
waste, and when you eliminate the waste, you speed up the process,”
says Leo Serrano, FACHE, CLSup (NCA), executive director of laboratory
services for West Tennessee Healthcare, Jackson, Tenn. Serrano and
his colleagues implemented Lean Management in January, and they’ve
seen a 77 percent reduction in the time between when a specimen
is collected and when it’s received in the lab. “And
that went a long, long way toward improving our performance and
customer satisfaction,” Serrano told CAP TODAY.

Going
with single-piece flowA
Lean lab processes specimens in the order they are received by creating
a standardized production line akin in principle to how Subway sandwich
shops move their products down a line of operators toward the cash
register. The more standardized the process, the better and more
consistent the product’s quality and turnaround time—and
the faster the cash flow.

To standardize
protocols for lab testing functions, laboratories implementing Lean
Management videotape their work and compare how they work to standard
operating procedures. “They then establish very specific work
instructions that everyone has to follow,” Jamrog says. For
example, all phlebotomists perform their work in the same way, follow
standardized routes, and use standardized carts or trays.

Phlebotomists
and operators in a Lean environment work on one specimen at a time,
unless it is necessary to batch specimens—for example, when
growing microbiology cultures or processing tissues in histology.
“But even then, you single-piece flow around areas that you
have to batch, which works well,” Serrano says.

On the front
end, the phlebotomists retrieve one specimen label at a time, identify
the patient, draw the specimen, label it, and send it by pneumatic
tube from the nursing station to the lab. Then they get the next
label without returning to the lab.

While it might
seem phlebotomists would chalk up more miles than usual with all
those trips to and from the pneumatic tube, the opposite is true,
Jamrog insists. “The walk time is actually reduced because
the phlebotomist is not repeatedly walking from the lab to various
assigned floors throughout the day,” he says. “Rather,
they are walking from the nurses’ station to the patient’s
room and back.”

The phlebotomists’
standardized carts are restocked at regular intervals from the back
so the oldest inventory is pushed forward and used before it expires.
Jamrog likens the process to restocking a pantry: “If someone’s
pantry is disorganized, the person doesn’t really know what
to go buy. But if they clean and organize it, it’s easy to
see that there’s an oversupply of chicken soup and many items
that have passed their expiration date.”

The single-piece
flow also lessens the opportunity for error, reducing it to virtually
nil in some cases. “In a batch environment, the phlebotomist
has multiple orders on the cart at the same time,” Jamrog
says, “so the possibility and probability of getting someone’s
blood mixed up with another person’s is higher than it needs
to be.”

Tackling
the workforce shortage
By reducing and balancing lab operators’ workload, Lean might
prove to be at least a partial antidote to the laboratory workforce
shortage. For example, Fairview Health Services, Minneapolis, which
is putting finishing touches on a Lean pilot project at its suburban
Fairview Southdale Hospital lab, is confident the new system will
improve productivity by 30 percent. And that will mean a reduction
in the need for full-time staff for automated testing, says Rick
Panning, MBA, CLS(NCA), president of laboratory services for the
health system.

“Fortunately,
we have been anticipating the staffing reduction and held many technical
positions open until the end of the project. We’ll also be
considering other opportunities for redeployment of staff,”
said Panning, in sharing his lab’s experience with Lean in
a case study presentation at the War College.

Serrano also
found that Lean reduced staffing needs, which made it possible for
management to reallocate staff to expand the lab’s test menu
and support its educational mission.

Lean also requires
all employees to pull their own weight by performing defined standard
work and hitting defined standard times. This approach allows workers
and managers to see points where the product isn’t flowing,
either because someone isn’t keeping pace or a machine is
down. “In some systems, you don’t readily see the slow
person who consistently does not handle a fair share of workload,”
Jamrog says. “We all experience that when we get in a line
at the grocery store or bank. If the line is too slow, people move
to another line, so it’s hard to visually see the person is
handling far fewer customers than average.”

Supervisors
in a Lean environment visually inspect for bottlenecks and monitor
output hourly and daily to determine if the lab is hitting its performance
benchmarks, which are based statistically on workers who know how
to do the job and represent the work ethic the system espouses.
The hourly monitoring is critical, Jamrog says, because it helps
supervisors “respond to misses in planned output. If you fall
behind in the first hour of the day, but don’t detect the
problem until the eighth hour of the day, you have created a situation
where you have zero time to respond to the problem.”

The Lean system
also addresses the need for automation, Jamrog told War College
participants. “For example, once you lay out the lab properly
so that a person can easily include transportation of the material
in the walk pattern, then management can see it doesn’t make
sense to invest in automation to move the specimen from machine
to machine.”

In other words,
automation is not always the answer to improving productivity, or
at least not the answer of first resort. The answer lies in creatively
developing low-cost “commonsense and practical mechanical
and industrial engineering solutions,” Jamrog said. “Then
you strategically and tactically place automation, if it turns out
to be necessary.”

‘Leaning
out’ the lab
The effort to “lean out” a lab is a methodical one that
gets to the nitty-gritty of how the specimen flows through the system
and how the employees do their work.

It starts with
a “Lean team,” which at Fairview Southdale Hospital
is composed of six people pulled from their jobs for 14 weeks. The
team includes management, a lead person from phlebotomy, a couple
of clinical lab scientists, and a representative of the performance
excellence program in the corporate division to lend an unbiased
eye to the project. Lab management pared a list of several employees
interested in volunteering for the team to six, selecting staff
members known to be informal leaders.

At the outset,
management observed that the equipment layout did not allow for
a smooth workflow and that testing was batched in many islands of
work, Panning said.

The Lean team
videotaped workers to document their processes, walking patterns,
and workflow, capturing the details of every task. The group concentrated
on testing in the clinical lab (hematology, chemistry, immunochemistry,
coagulation, and urinalysis). Based on methodical analysis and graphing
of the videotaped data of workers’ activities and the specimen
flow, the team designed one work cell, rather than separate departments,
for all of these areas of testing. This work cell accounts for more
than 90 percent of the testing performed in the clinical laboratory.
The Lean team is also standardizing the specimen collection and
processing part of the lab.

“The work
cell is one space that includes the instruments and tasks assigned
to that cell,” Panning explains. “We hope to assign
two to three people to work in that environment as one cell ...
and will do one-piece flow where the technical staff focus on one
specimen at a time. These same areas were formerly staffed by five
to six people on the day shift.”

To eliminate
distractions, the Lean team identified and moved interruptions “somewhere
else for other people to handle,” Panning says. “That
way the clinical laboratory technical staff can focus on what provides
value, which is taking the specimen and producing the result.”

At CAPTODAY
press time, people in the Fairview Southdale laboratory were being
trained to do their work in standardized ways. That’s where
Lean gets mean: “No longer can someone come in and redesign
their workspace,” Panning says emphatically. To prevent that
from happening, the Lean team used shadowing to outline where everything
should go, down to the phones and staplers. Serrano’s laboratory
used tape to do the same.

Panning reports
that while some lab staff initially found the shadowing to be unnecessary
for professionals, they now understand it helps them perform their
jobs better. “Lack of standardization introduces so many chances
for error and delay,” he says. “And we have situations
where someone goes to lunch or on break and another person takes
over for him or her, which is very difficult to do” when everyone
has designed their own workspace.

Yet management
stressed to its employees that the move to Lean was designed to
improve human potential, not to penalize people, says Panning. “One
of the major messages we had to convey to staff is that we didn’t
start this project because they weren’t working hard,”
he says. “We communicated that we know they work hard but
their performance could only be as good as the old system allowed.”

Not
exactly lean results
Fairview’s Lean project is producing other, unexpected results.
“For one, we freed up so much space that we were able to create
a new space for microbiology. They get to occupy what used to be
our chemistry lab, and other space will be converted into a Lean
storage space,” Panning says. But instead of moving into the
new space and going about business as usual, the microbiology department
laid out the space, including instruments and incubators, so that
work flows logically. (The scope of the original Lean project was
expanded to accomplish this.)

Lean will not
only improve turnaround time in the lab, but also make the reporting
of test results more consistent—so much so that Panning expects
the system may question the raison d’être of the “stat”
designation because everyone should consistently get test results
when they expect them.

Lab managers
are now speaking with physicians about what tests they need stat
and why. “In the old days I might have blamed physicians for
misusing the stat designation,” Panning admits. “But
I think it was a defense mechanism on their part where they’d
order a test stat just to get the results in a normal time frame.

“We’ll
be educating physicians and clinical staff in the patient care units
about the realities of how fast the system can work,” Panning
adds. “We can now set reasonable turnaround targets which
will meet the customer’s needs and are based on the new capabilities
of the system. We shouldn’t try to aim for a 20-minute troponin
if the capabilities of the system, at its best, can’t deliver.”

Fairview Health
Services, in fact, did a form of what Panning calls “Lean
Lite” in a project in the Fairview-University Medical Center.
The project focused on stat orders, improving consistency, and reducing
errors and turnaround time. The person who led the project, Cindy
Hudson—a soon-to-be-certified black belt in Six Sigma—eliminated
a lot of the clutter in the workspace and used the 5S system of
workplace organization and standardization developed in Japan. “Every
cupboard and drawer was reorganized and is now supplied so you can
tell what’s needed,” Panning says. “The project
didn’t involve the rigor of Lean, but it did reorganize the
work area.”

Implement
Lean and Six Sigma will come
How does Lean fit with statistical performance improvement systems
like Six Sigma or ISO? “Like hand and glove or foot and shoe,”
Jamrog says. Panning and Serrano agree, noting that when you “lean
out” a lab by removing waste, the Six Sigma projects, which
require root-cause analysis, readily emerge.

Lean can result in significant improvements that substantially change laboratory
processes.

Lean may eliminate a process that was causing an error.

Once the lab fixes/leans out its processes, the focus shifts
to other areas because the lab has fixed other known quality process
problems by simplifying and standardizing. Or, in some cases,
the lab may not see the real cause of a problem until it is leaned
out.

Says
Maureen Harte, a Six Sigma master black belt with Ortho: “Until
Lean removes waste from the system, you can’t fully identify
the variable processes that truly take a bite out of the bottom
line.”